Community Shul of Montecito and Santa Barbara

2009/2010 School Year Registration Form

Student’s Name: ____________________________   Grade entering in Fall: ____

Address (with zip code): _______________________________________________

Phone #: __________   E-Mail we can send information to: ____________________

Sex (circle one):  Male     Female       Date of Birth: ________________ Age: _______

Mom’s (Guardian’s) Name: ________________________________________

Home Phone: _______________    Work: _______________   Cellular: _____________

Dad’s (Guardian’s) Name: __________________________________________

Home Phone: ________________   Work: _______________   Cellular: _____________

Doctor’s Name and Phone Number: ______________________________________

Medical Conditions, please give particular instructions, i.e. allergies: ______________

_______________________________________________________________________

Emergency Contact: ________________________     Relationship: _____________

Home Phone: ______________ Work: _________________   Cellular: __________

Emergency Contact: _________________________     Relationship: ______________

Home Phone: _______________ Work: ____________   Cellular: _________________

Fees: 1^st-5^th grade students - $1,250 per child         B’nai Mitzvah class - $1,250 per child An additional fee of $1,500 during the year of your child’s Bar/Bat Mitzvah

*Early Bird Special- $100 discount per child if paid and postmarked by June 30^th

$100 multiple child discount

Please return registration form with a check made out to:

The Community Shul of Montecito and Santa Barbara (CSMSB), P.O. Box 994, Santa Barbara, CA  93116-0994

($50 per child non-refundable deposit required to reserve a space in the school.)

Tuition covers faculty salaries, textbooks, supplies, JCC usage, insurance, field trips, and special events. Over >>>>>>

Questions ???

…about 1^st-5^th grade program,  B’nai Mitzvah program, tuition, and setting up a payment plan, e-mail, Itzik Ben Sasson, Education Director, at Itzik7@cox.net

or call  805-895-6593

…about life cycle events and scholarships, call Rabbi Arthur Gross- Schaefer at

                       agross@lmumail.lmu.edu   or call 805 683-4561

Community Shul Release Form

The parties hereto have joined to form an educational cooperative for the express purpose of providing a basic Jewish cultural education to their children.  The Santa Barbara Jewish Community Center is providing classroom-type facilities.  The parties may also from time to time hold events at their private residences.  The undersigned is on behalf of themselves and as guardian ad litem for the minor child/children.

_____________________ does hereby release and discharge all parties who are members in the educational cooperative and who may provide their home for classroom or event purposes, including, but not limited to the Santa Barbara Bronfman Family Jewish Community Center from any and all liability, claims for injuries and damages that may occur while any activity is being conducted on their premises.

____________________                                                  ________________

Signature of Parent/Guardian                                                      Date

Medical Release Form

Physician’s Name: _____________________________ Phone:______________

I, the undersigned, parent/person having legal custody/legal guardian of __________________, a minor, do hereby authorize the Community Shul as agents for the undersigned to consent to any medical or surgical examination, diagnosis, treatment or hospital care, which is deemed advisable by, and is rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agents to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his or her best judgment, deem advisable. These authorizations shall remain effective until revoked in writing, delivered to said agents.

PARENT/GUARDIAN’S SIGNATURE                                                             DATE